Laserfiche WebLink
Y f r <br /> t g C7eck TO UI 1 tto pj3l49 /0037 <br /> commerce.ty Safety'and Buildings Division County <br /> ,. 010W.Washoing ton Ave.,P.O.Box 7162 `;)! N i s co n S n S E p 1 72 O&eladisn,WI 53707-7162 E <br /> Sanitary Permit Number(to be filled in by Co.) <br /> Department of commerce 5/8/46 _ <br /> State Transaction Number <br /> San' aryE�ert Apcation <br /> In accordance w i t h s.Comm.83.21 C e d e,submis i i i f o f t l v 3 firm to the appropriate govermnental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary alb'C. 5 f_N D pi-t(,(_ t1� <br /> purposes in accordance with the Privacy Law,s.15.04(1 Xm),Stats. <br /> L Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Ga-2-'r L E_ Gur 11-oul b G( o _ 2,3 —. 17c Yu -i <br /> Property Owner's Mailing Address Property Location <br /> 2 i8a 5 K-kLL cam_ Al <br /> �y <br /> City,State Zip Code Phone Number 1?�'60/ v, '/4, Section 2 0 <br /> C 6--0 w.J ` W l S 3.5 7 C- &)) 0 t a. - 1 Z Z Z T N; R / o E <br /> IL Type of Building(check all that apply) <br /> a(Or 2 Family Dwelling-Number of Bedrooms ' <br /> Subdivision Name <br /> • Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number n❑Village of <br /> -7 �8 l7'lownof 10 t.rf.'-, <br /> III.Type of Permit: (Check only one box on line A Complete line B if applicable) <br /> A ❑New System N'?lacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> Li <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber CI Permit Transfer to Newer Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> EFNon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation 7(4-7 <br /> C. °`. e,-� l v o.7 !es S ° 9S-f> S•-2. 1`S-Y`S 9.I'.�,i <br /> VL Tank Info Capacity in Total #of Manufacturer = a i I 1 <br /> Gallons Gallons Units c ® + • <br /> New Tacks Existing Tanks c m .90 a 2 <br /> ct U :n m m U." F5 a, <br /> septic orAsielitig Tank /z Ses — I Z S' _ 1 DALMARAY X <br /> Dosing Chamber 7 S U — 7 5L) ( f 1 17 <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI 's Signature /, Number Business Phone Number <br /> KURT HAMILTON � 224-286 (608)897-4262 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> SCHLITFLER CONSTRUCTION, P.O.BOX 154, BRODHEAD,WI 53520 <br /> VIII County/Department Use Only __ ti owed ❑ oved Permit Fee Date Issued Issu .: Si;.. ..- Zz <br /> ❑Owner Given Reason for Denial $ ,-3';,77-7----- <br /> ` c C! `8/�Od ��''/ .,-;-'1 joi <br /> IX Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1!2 z 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />